Face Transplants: Getting Closer to a Standard of Care

Another face transplant was performed last week by plastic surgeons at the Brigham and Women's Hospital in Boston. This is the fourteenth face transplant that has been reported worldwide. The first was performed by French surgeon Jean-Michel Dubernard and his team in 2005. Successful face transplants have now been performed in France, Spain, China and the USA.

The indication for this aggressive surgery is severe facial disfigurement -- disfigurement that cannot be reconstructed by conventional plastic surgical techniques. The first U.S. face transplant patient, Connie Culp, received her treatment at the Cleveland Clinic in December, 2008. Connie was a victim of domestic violence who had received a shotgun blast to her face.

The tissue loss was so severe that multiple reconstructive procedures provided little improvement.

As shown in figure 1, (and similar to all face transplant recipients to date), the improvement in her facial appearance after surgery was dramatic.

[ Figure 1. The nation's first face transplant patient, Connie Culp, has done remarkably well following surgery in December, 2008 at the Cleveland Clinic. Photographs show pre-op appearance in 2008, post-op appearance in May 2009, and her appearance after some refining surgery in August 2010. ]

Connie expressed her satisfaction with this surgery and the positive impact it has had on her life during a live radio interview on Sirius XM's Emergency Medicine Show on Doctor Radio with Chad Gordon, D.O. (one of the eight Cleveland Clinic face transplant surgeons).

Does the technical success of these procedures indicate that transplants should be a standard approach to treat the severely facially disfigured? Probably not ... yet.

Two of the 14 face transplant recipients have died from complications related to the procedure. Both deaths were related to the immunesuppressive medications that these patients must take to prevent the body's rejection of the transplant. The immunosuppressive drugs probably limited a patient's ability to fight an overwhelming infection and led to his death soon after transplantation. Another patient died after being non-compliant in taking his medications.

With visceral organ (kidney, liver, lung, heart, etc.) transplantation, the risks of transplantation are overwhelmingly outweighed by the benefit of the organ transplantation -- life. However, the benefit after face transplantation is an improvement in the quality of life. Therefore, it is more difficult to justify the procedure.

The key to improving the risk-benefit ratio for face transplantation is to decrease the risks of, or better, eliminate the need for chronic immunosuppression. The successful transplantation of human kidneys without chronic immunosuppression was reported by workers at the Transplantation Unit at the Massachusetts General Hospital in 2008.

This team introduced stem cells from the organ donor into the recipient's body. As a result, the recipient developed the immunologic identity of both bodies, making it tolerant of the transplanted kidney (which the recipient's body now sees as part of itself). Dr. Curt Centrulo is working with this group to apply this technique to the transplantation of nonvisceral tissues (muscles, skin, fat, bone and tissues) -- the essential components of face (and hand) transplants.

At this time, face transplantation is still experimental and should be reserved for well-selected individuals with severe facial disfigurement non-applicable to modern-day reconstructive techniques. This type of transplant should only be performed by experienced, multi-disciplinary teams at university-based institutions under an investigative review board (IRB) protocol.

Because of the tremendous risks associated with the transplant immunosuppression (at this time, lifelong immunotherapy is required), each candidate's risk-to-benefit ratio should be critically reviewed by a team of doctors and surgeons, including a bioethicist and transplant psychiatrist. However, as less toxic immunotherapy methods evolve, particularly with the potential for inducing tolerance (as with stem cells) and thereby eliminating the need for chronic immunosuppression, face transplantation may soon become a more standard care for the severely facially disfigured.